| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
680 |
680 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
392 |
392 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
707 |
707 |
$13K |
| D0272 |
Bitewings - two radiographic images |
614 |
614 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
310 |
283 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
57 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
338 |
338 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
80 |
$7K |
| D0240 |
|
512 |
294 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
37 |
28 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
328 |
326 |
$4K |
| D1351 |
Sealant - per tooth |
149 |
51 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
306 |
297 |
$3K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$658.26 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$484.92 |